Preoperative antibiotics in biliary surgery

Biliary excretion of moxalactam

The biliary excretion of moxalactam was studied in 11 postsurgery patients who had indwelling T-tubes inserted in their common bile ducts. Peak levels of moxalactam in the bile reached mean levels of 33.7 +/- 11.1 and 173.7 +/- 67.0 micrograms/ml 2 h after intravenous administration of a single 500- or 2,000-mg dose, respectively. In 5 of the 10 patients given the 2,000-mg dose, peak moxalactam concentrations in the bile were 2 to 12 times higher than simultaneous serum levels, but considerable variation in the biliary excretion of moxalactam was observed among the individual patients.

Use of prophylactic antibiotics in surgical practice

During the last decade great inroads have been made concerning the appropriate use of antibiotic prophylaxis in the surgical patient. Well-controlled, prospective, blinded studies have outlined many of the areas in which antibiotic prophylaxis is of benefit, as well as those clinical situations in which the risks of antibiotic prophylaxis outweighed the expected value. Historically, the most common errors in usage include the widespread use of antibiotic prophylaxis in clean surgery and the faulty timing of administration. The most common error today (in the use of prophylactic antibiotics in surgical practice) is continuation of the agents beyond the time necessary for maximal benefit. In order to appropriately administer prophylactic antibiotics in the various clinical settings on the surgical service, in which this practice has been of proved value, one must be aware of the following nuances including (1) choice of the antibiotic agent based on the type of organisms usually causing infection, (2) route of its administration, (3) the dosage necessary to attain efficacious tissue or serum levels, and (4) the timing of administration which offers the maximum benefits without risking the adverse effects.

Empyema of the gallbladder: a complication in the natural history of acute cholecystitis

Empyema of the gallbladder was identified in 34 patients. Patients undergoing early operation without attempts at nonoperative treatment had less infectious morbidity and mortality. Delayed operative intervention, extrabiliary abscess, perforation of the gallbladder and common duct exploration are factors that contribute to increased risks in these patients.

Prophylactic use of metronidazole in preventing wound sepsis after elective cholecystectomy

The effect of intravenous metronidazole as prophylaxis against postoperative wound infection was studied in a prospective, randomized, double-blind controlled trial of 116 patients undergoing elective cholecystectomy. No significant difference was found in the infection rate between the treated and the control groups.

Determinants of adverse reaction following postoperative T-tube cholangiogram

The incidence, nature, and mechanisms of adverse reaction following postoperative T-tube cholangiogram have received little attention in the medical literature. This paper presents the experience at one hospital over a 30-month period (1975--1977) covering 139 patients who had 170 cholangiograms. Factors examined included intraoperative and postoperative cultures of bile, the use of antibiotics prior to the performance of the cholangiogram, the technique of cholangiography, the interval between operation and cholangiogram. Eleven (6.5%) cholangiograms were followed by an adverse reaction. Two of these reactions were severe, manifested by signs of septic shock. The administration of antibiotics was not associated with a reduction in adverse reactions. The cholangiographic technique of gravity infusion of dye, which effectively limits the amount of pressure generated during the study, was associated with a significant reduction in adverse reactions. No severe reactions occurred following any study performed by the gravity technique. There was no significant correlation between the age of the patient or the number of days postoperative with adverse reaction. A review of the literature suggests that the mechanism for these severe reactions is cholangiovenous reflux. The avoidance of high intraductal pressures (above 25 cm of water) during the performance of postoperative T-tube cholangiogram should significantly reduce the incidence of adverse reactions.

Perioperative care of patients with cardiac disease

Patients with cardiovascular disease commonly present with problems requiring surgical treatment. They are more vulnerable than patients without cardiovascular disease to the cardiovascular stresses associated with general anesthesia and surgery--hypotension, hypoxemia, sepsis, and thromboembolism. Their risk of morbidity and mortality is higher. Certain clinical factors have a profound impact on the patient's likelihood of serious cardiac complications or death: Overt heart failure, recent myocardial infarction, and cardiac arrhythmias are the most worrisome. A careful clinical evaluation and formal assessment of the patient's risk dictate better perioperative monitoring and treatment. Early hospital admission provides time for control of other health problems. Prophylaxis with heparin and antimicrobial agents minimizes problems of thromboembolism and sepsis, respectively. Overaggressive treatment of hypertension is avoided, and withdrawal of propranolol or clonidine is carefully supervised. The use of digoxin is restricted to patients with atrial tachyarrhythmias or heart failure. Hemodynamic monitoring via a Swan-Ganz catheter or temporary transvenous pacing may be necessary for selected high-risk patients. Such careful evaluation, monitoring, and treatment are the clinician's methods for improving the chance for patients with heart disease to benefit from surgery.

Antibiotic prophylaxis in gastric, biliary and colonic surgery

Antibiotic prophylaxis for surgery has appeared indicated whenever likelihood of infection is great or consequences of such are catastrophic. For better clarification, a prospective, randomized, double-blind study was run on 400 patients undergoing elective gastric, biliary, and colonic operations. There were four treatment categories, with antibiotic being instituted 12 hours preoperatively, just prior to operation, after operation, or not at all. During operation, samples of blood, viscera, muscle, and fat were taken for determination of antibiotic concentration. Both aerobic and anareobic cultures were also taken of any viscus entered, peritoneal cavity, and incision. Similar cultures were run on all postoperative infections. Results demonstrated that the incidence of wound infection could be reduced significantly by the preoperative administration of antibiotic in operations on the stomach (22% to 4%), on the biliary tract (11% to 2%), and large bowel (16% to 6%). Less impressive results were obtained for peritoneal sepsis. Initiation of antibiotic postoperatively gave an almost identical infection rate as if antibiotic had not been given (15% and 16%, respectively).

Comparative biliary concentrations of cephazolin and cephalothin in patients with biliary tract disease

The concentration of cephazolin in the serum, gall bladder bile, common duct bile, and gall bladder wall were consideredably higher than cephalothin especially with IV administration and indicate that cephazolin should be a useful antibiotic in the surgical treatment of acute cholecystitis.

Gallbladder disease in children and adolescents

Seventy-nine patients, twenty years old or younger, with cholecystitis underwent cholecystectomy during a five year period at Santa Rosa Medical Center. There was a considerable delay in diagnosis in many cases. Etiologic factors differed with race and age; however, the disease appears to be quite similar in adolescents and adults. Hemolytic disease was present in all five blacks but in none of the remaining seventy-four patients. Patients younger than ten years of age are more likely to have congenital anomalies or infectious etiologies for the gallbladder disease. Cholecystectomy was associated with minimal morbidity and no mortality in this series. Cholecystitis should be considered early in the child or adolescent with unexplained abdominal pain, and oral cholecystograms proved to be a safe and reliable method of diagnosis.

Prophylactic antibiotics in noncardiac thoracic operations

A high incidence of thoracotomy wound infection and empyema in 1972 was associated with inadequate and irregular administration of prophylactic antibiotics. Beginning with 1973, a strict regimen was adopted that combined systemic cephalosporins and two topical antibiotics (cephalothin and kanamycin). Emphasis was placed on preoperative administration of the systemic agent and on use of the topical drugs before the operative field was contaminated. The patient groups for 1972 and 1973 were similar in most respects, but the wound complication rate was 18.4% in 1972 and 4.8% in 1973.

Pancreatic pseudocysts

Pseudocysts are fascinating lesions of the pancreas which present as upper abdominal masses in about 80 per cent of cases, but also as obstructive jaundice, intrasplenic and intra-left-renal masses, mediastinal masses, flank abscess, pleural effusions, and ascites rich in amylase. They are diagnosed by urine amylase with greater sensitivity than by serum amylase. Cysts must be differentiated from pancreatic abscesses, indolent phlegmonous pancreatitis, cystadenomas, and carcinomas of the pancreas, as well as lymphomas and other rare tumors. They may be satisfactorily treated by large sump tube drains to the outside but about one third will require a further operation. Internal drainage by cystogastrostomy is the simplest and best current procedure, but not applicable to all cases. A good alternative is Roux-en-y cyst-jejunostomy. Caution is needed in the preoperative workup since all procedures are accompanied by an operative mortality approaching 10 per cent, mostly due to hepatic disease, portal hypertension, stress ulcerations, and hemorrhage. The follow-up shows 85 per cent good results from proper drainage but 40 per cent are diabetics and in many patients the ravages of alcoholism continue unabated.

A controlled trial of parenteral prophylactic gentamicin therapy in biliary surgery

This trial has investigated the value of gentamicin therapy in patients requiring biliary surgery. One hundred consecutive patients were randomly allocated to receive either gentamicin or no antibiotic. Post-operative infection was assessed by an independent observer. Cultures and gentamicin assays were performed on bile and blood sampled during and after operation. The minimum inhibitory concentrations of gentamicin were measured with isolated bacterial. In 80 per cent of patients biliary organisms were inhibited by 2 mug/ml of gentamicin. Twice this concentration was found in the serum at operation in 88 per cent, but in the bile in only 18 per cent. Nevertheless, gentamicin lowered the incidence of bacteria in the bile from 42 to 25 per cent. There was a reduction in wound sepsis from 21 to 6 per cent (P less than 0-05). Bacteriaemia was demonstrated in only 1 patient receiving gentamicin compared with 5 controls and 1 death occurred from endotoxaemia in the control group. These data suggest that gentamicin will reduce the morbidity of biliary surgery, particularly in patients in whom the bile is infected at operation.